Page 253 - EJMO-9-3

Eurasian Journal of
Medicine and Oncology Nursing students’ views on advance directives

status or medical background of the participants’ family competencies throughout the course of study, as supported
members, which could have influenced students’ emotional by Dimoula et al. and Muliira et al. 25
18
responses and preferences regarding end-of-life decisions. The results also highlight the value of active learning
This represents a potential unmeasured confounding factor. strategies, such as case discussions, simulation, and role-
While the homogeneity of the cohort (3 -year nursing play. These pedagogical methods have been shown to
rd
students from the same institution) ensured internal deepen understanding and foster empathy, particularly in
consistency, it also limited external validity, particularly in emotionally complex contexts of end-of-life care. 20,27 By
relation to diverse cultural or institutional contexts.
confronting students with complex scenarios, they help
Second, the short-term nature of the assessment— them develop confidence and relational competence when
conducted immediately before and after the educational addressing sensitive issues such as therapeutic limitation
intervention—precludes drawing conclusions regarding and patient autonomy.
the long-term retention of knowledge or sustained changes Shifts in students’ views on spiritual and post-mortem
in attitudes and behavior. Third, although the study
included a thematic analysis of open-ended responses, it preferences suggest the importance of providing culturally
lacked in-depth qualitative data (e.g., interviews or focus sensitive education that incorporates spiritual beliefs,
personal values, and family dynamics as integral aspects
groups) that could have provided richer insights into the of holistic palliative care. The literature confirms that
students’ emotional and ethical reasoning processes.
cultural and spiritual factors profoundly influence end-
Furthermore, the study did not collect data on of-life decisions. 13,16 Educational interventions that use
participants’ ethnicity or geographic origin. While this intercultural case vignettes and facilitate structured ethical
reflects the relatively homogeneous composition of the reflection may better prepare students to support patients
nursing student cohort, it limits the analysis of cultural from diverse backgrounds with cultural humility.
differences in perceptions of AHDs. The relatively small
sample size also limited the statistical power of the study, Another important implication is the need to integrate
and the absence of statistically significant findings may interprofessional education into palliative care training.
be attributable to this limitation. It is also important to Learning environments that bring together students of
note that no a priori power analysis was conducted to nursing, medicine, social work, and other allied health
determine the minimum required sample size. Another professions can enhance communication skills, clarify
limitation concerns the use of a non-validated instrument. professional roles, and foster collaboration—key elements
Although grounded in national guidelines, the lack of for delivering integrated and patient-centered care in
psychometric evaluation could reduce the interpretability multiple clinical settings. 31,45-49
and generalizability of the findings. Finally, the emotional demands of palliative care call
Future research should address these limitations by for strategies that promote emotional resilience and moral
employing multicenter randomized controlled trials with integrity among nursing students. Incorporating structured
larger sample sizes and more diverse educational settings. debriefings, peer support mechanisms, and guided ethical
Longitudinal follow-up studies are also warranted to discussion, particularly after emotionally intense learning
assess the durability of attitudinal and behavioral changes experiences, can help mitigate moral distress and prepare
over time, particularly during clinical placements or students for the psychological challenges of end-of-life
37
post-graduation. Moreover, incorporating qualitative care. As emphasized by Rushton et al., cultivating moral
methodologies, such as narrative interviews or focus resilience is essential for sustaining compassionate and
groups, could provide deeper insights into the nuanced ethically grounded nursing practice over time.
ways in which educational interventions shape students’ 5. Conclusion
moral development and communication strategies in end-
of-life care. This study suggests that a targeted oncology palliative care
module may enhance nursing students’ understanding and
4.2. Clinical and educational implications attitudes toward AHDs, although the observed changes

The findings of this study have significant implications for were not statistically significant. Key outcomes included
both nursing education and clinical practice. Integrating an increased preference for refusing non-beneficial
AHD content longitudinally into nursing curricula, rather treatments and heightened awareness of the need for
than confining it to isolated modules, is a key educational improved communication regarding therapies and pain
strategy. This approach supports the reinforcement of management. Although a slight decline in willingness
ethical principles, communication skills, and reflective to donate organs was observed—potentially reflecting

Volume 9 Issue 3 (2025) 245 doi: 10.36922/EJMO025250263